MEMBERSHIP FORM:

THE FOLLOWING INFORMATION WILL BE

ENTERED INTO THE CLUBS

MEMBERSHIP DATABASE:

Name: _____________________________  Call sign: _________________

Address: ___________________________

City: ________________________   Zip: _____________

Telephone: _______________________

Email address: _____________________

License class: __________________ (technician, general, advanced, extra)

License expiration date: _________________

ARRL member?  _________  ( yes or no )

Areas of interest in ham radio:  __________________________________

___________________________________________________________

Suggestions for programs and activities during 2015: _________________

__________________________________________________________

___________________________________________________________

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RECEIPT FOR 2015 MEMBERSHIP DUES PAYMENT – NIRAA: W0MG:

Date paid: _____________  Amount paid: $_____________  ($20.00)

Members name: _______________________________

_________________________________Scott W. Lowe, WA0TPN, Treasurer 110 Spruce St.

Reinbeck, IA 50669

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